Where's the engineer of this train wreck?

Every year in the U.S., 1.5 million people are harmed by medication errors, events that add billions of dollars to the healthcare economy. The medication use system we rely on is a lot like a train sent down the tracks without an engineer. Not only was it not "engineered" in the first place, few people on the train understand everything necessary to ensure its safe operation. Worse, most people on board wrongly assume that someone is, indeed, in charge and sit back, assuming they are free to relax and enjoy the ride.

Maximizing the safety of medication use is no short journey. You start with a complex system that involves licensed individuals, crosses the disciplines of medicine, pharmacy, and nursing, is highly regulated, has deep-pocket special interest groups, and requires a high degree of cooperation and communication amongst professionals and consumers. Oh, and to cement your joy, if you include the word "medication" in a sentence, you've just catapulted the instructions out of the range of the fifth grade reading level that health materials are supposed to be written at. ("Medicine," yes. "Medication," no.)

Medications have to be prescribed (or for OTCs, selected by consumers) dispensed, administered, and, in some way, shape, or form, monitored for effectiveness. For warfarin, the rat poison that mitigates inappropriate blood clotting, monitoring involves serial tests run on blood samples. At the other end of the spectrum are birth control pills, where monthly periods suffice. (Sadly, variability is not the friend of reliability.)

Systems engineers speak of "failure points," predictable places where errors are likely to occur. For example, not knowing that a patient takes warfarin when he or she presents for treatment of another condition is a known failure point that can be predicted to result in medication-related harm.

"Failure finding tasks," "performance shaping factors," and "exposure rates," are engineering concepts that rarely make their way into curricula used to prepare healthcare professionals. Yet when it comes to getting desired health outcomes what healthcare professionals know about how a system works may be as important as knowing how a person's system works.

Systems engineers also learn to design work processes to achieve three distinct safety-sensitive outcomes:

1. prevent errors (operative words: barriers, constraints)


2. discover errors set in motion before they cause harm (operative words: redundancy, "failure finding" tasks)


3. mitigate the potential for errors to cause harm (operative words/concepts: recovery, rescue)

There's a host of things that can be done to improve safety when medications are used. But the first step (and remember, this is always the first step) is to recognize that we--all of us--have a problem. If you prescribe, dispense, administer, or take medications, you have a problem: you're riding in a runaway train.

The good news is that the language of systems engineering can be learned, and concepts adopted and adapted to retrofit the medication use system. And you have a role, no matter where you're coming from. I'm going to begin an occasional series, describing specific actions and activities that can be used to strengthen the system. You'll find these posts are indexed with the label "engineering." All aboard? I hope you'll come back soon!